Eyeworld

JULY 2023 | EYEWORLD | 55 R Contact Ling: josephjling@gmail.com Loden: lodenmd@icloud.com Relevant disclosures Ling: None Loden: Johnson & Johnson Vision concerned about quality of vision. If vision is fluctuating, he explains that the tear film is a big part that is recovering after laser vision correc- tion. Artificial tears need to be used frequently, Dr. Ling said. With PRK, this requires a longer period for the vision to stabilize, as the surface of the epithelium needs to heal. Diagnostic tests In terms of diagnostic tools and tests that can be used to help patients after surgery, Dr. Loden said he uses OCT to ensure the patient does not have any CME that needs to be treated. This is generally for the cataract and lensectomy patients, he said. Another postop issue is uncorrected refrac- tive error. It's the number one cause of com- plaints and dissatisfaction, whether it's spher- ical or cylinder. Dr. Loden said he will put the patient in a trial frame with their best correction and ask how it looks to determine how to best proceed with a touch-up procedure. Dry eye is another common problem post-surgery, Dr. Loden said. It might be neces- sary to use Placido disc topography. Dr. Loden also likes to use the Visiometrics HD Analyzer to measure objective scatter index. Any of the tear film analyzers are helpful to see whether the pa- tient has dry eye or a poor quality tear film that needs to be addressed, Dr. Loden said. When there is an unexpected refractive error in laser vision correction, Dr. Ling said he checks the Pentacam (Oculus) to make sure the cornea appearance is as expected and there is no ectasia or abnormalities. He also checks pa- tients for dry eye with fluorescein tests to make sure they are using artificial tears frequently enough. Dr. Ling suggested checking the refrac- tion at 1 week and 1 month in order to have a comparison. Patients will see a change from the 1-week refraction, but this gives him a sense of where they are and the types of issues they might be having. He typically waits until 3 months after surgery to decide if the patient will need an enhancement. "For laser vision correction, if any touch- up needs to be done, we will usually know by 4–8 weeks out because the refraction stabilizes around that time," Dr. Ling said, adding that the range for that enhancement is low, around 1–2%, depending on the type of surgery and how high the prescription is. "The higher the prescription you're treating with laser vision correction, the higher the chance that there may be a need for enhancement," he said. With ICL procedures, Dr. Ling said he looks closely at the vault of the ICL. "You can check that at the slit lamp by using a diagonal beam to see the space between the ICL and the natural lens and compare that to corneal thickness," he said. It's important to check the vault to ensure that the ICL size is suitable. If you're not sure about the vault through slit lamp, you can get an anterior segment OCT (Optovue Avanti) and measure the exact vault of the ICL over the crystalline lens. "For ICLs, we'd typically be looking at laser vision correction touch-ups and would figure out at about 1 month what the refraction stabi- lized at," Dr. Ling said. "You want to have more than one refraction to base that off of." If a patient's vault is too low (if there's less than 100 microns of space between the lens and ICL), there might be a risk of earlier cataract formation, Dr. Ling said. He usually likes to size up for that patient. If the vault is too high (above 750 microns and you have trouble see- ing the trabecular meshwork angle on goniosco- py), he'd want to size down. That would allow the trabecular meshwork angle to open up, so you don't run the risk of having angle closure, he said. Taking care of patients postoperatively is an art, Dr. Ling said. "There are many reasons why a patient might not be happy after their vision correction surgery," he said. "We try to head off a lot of the concerns preoperatively by matching the right patient to the right technology." There will still be patients who are not 100% happy, and that can be due to many non-surgical rea- sons. "You want to address expectations upfront to help ensure happier patients. If problems arise after surgery, empathize with the patient's concerns, reassure the patient's worries, and reaffirm that you are going take care of them every step of the way," he said. With proper expectation setting and handling of surprises in a confident and methodical manner, the patient and surgeon can benefit greatly from modern vision correction. Source: Joseph Ling, MD

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